WāhiBJJ
Brazilian Jiu-Jitsu and Self Defense
“I, _______________________________, have enrolled in the personalized health and fitness program offered through WāhiBJJ. I recognize that the program may involve strenuous physical activity including, but not limited to, muscle strength and endurance training, cardiovascular conditioning and training, and other various fitness activities. I hereby affirm that I am in good physical condition and do not suffer from any known disability or condition which would prevent or limit my participation in this exercise program. I acknowledge that my enrollment and subsequent participation in purely voluntary and in no way mandated by WāhiBJJ.”
WāhiBJJ
24 Turners Road
Feilding 4702
“In consideration of my participation in this program, I,______________________________, hereby release WāhiBJJ and its agents from any claims, demands, and causes of action as a result of my voluntary participation and enrollment.”
“I fully understand that I may injure myself as a result of my enrollment and subsequent
participation in this program and I, ___________________________________, hereby release WāhiBJJ and its agents from any liability now or in the future for conditions that I may obtain. These conditions may include, but are not limited to, heart attacks, muscle strains, muscle pulls, muscle tears, broken bones, shin splints, heat prostration, injuries to knees, injuries to back, injuries to foot, or any other illness or soreness that I may incur, including death.”
Participant. Emergency Contact.
First Name: .
Surname: .
Email: .
Phone: .
⎕ Consent to reminders/communication via sms
⎕ Consent to reminders/communication via WhatsApp
WhatsApp username: .
Please Turn Over
Health Details
Yes | No | |
Do you have any health problems or conditions: | ||
If so what: eg - epilepsy, faints, asthma, joint problems | ||
Do you have any allergies or sensitivities? | ||
If so what is your allergies/sensitivities to? eg - latex, rubber, nuts | ||
Do you have any infectious, contagious or problematic blood or skin conditions we should be aware of? | ||
If so what and how can we help or mitigate the risk: eg HBV, HCV, HIV, TB, anaemia, problems with clotting, or haemoglobin disorders |
I HEREBY AFFIRM THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE STATEMENTS.
___________________________ (Participant/Guardian/Parent Signature)
___________________________ (Date)
___________________________ (Coach Signature)
___________________________ (Date